Overview of Bariatric Surgery

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1 Overview of Bariatric Surgery To better understand how weight loss surgery works, it is helpful to know how the normal digestive process works. As food moves along the digestive tract, special digestive juices and enzymes arrive at the right place at the right time to digest food and absorb calories and nutrients. After we chew and swallow our food, it moves down the esophagus to the stomach, where a strong acid and powerful enzymes continue the digestive process. The stomach can hold about three pints of food at one time. Food is slowly released into the small intestine where absorption of the nutrients, vitamins and minerals takes place. The rate at which foods and fluids are released into the small intestines is controlled by a sphincter on the outlet of the stomach. Empty time can be over several hours. Normal Stomach

2 Gastric Bypass Operations Gastric bypass surgery is an operation that creates a small pouch to restrict food intake and bypasses a segment of the small intestine. In the gastric bypass procedure, a surgeon makes a direct connection from the stomach pouch to a lower segment of the small intestine, bypassing the duodenum (the first part of the small intestine) and some of the jejunum (the second part of the small intestine), delaying the mixing of ingested food and the digestive enzymes. Roux-en-Y Gastric Bypass Surgery (RYGB) RYGB is the most common type of bariatric surgery. The surgeon begins by creating a small pouch by dividing the upper end of the stomach. This restricts the food intake. Next, a section of the small intestine is attached to the pouch to allow food to bypass the duodenum, as well as the first portion of the jejunum. The small intestine is re-connected 150 centimeters from the pouch to allow ingested food and digestive enzymes to mix. The advantages of Roux-en-Y gastric bypass include superior weight loss when compared to vertical banded gastroplasty, with excellent long-term weight reduction and resolution or elimination of comorbidities (80 percent resolution of Type II diabetes after surgery). Early and late complication rates are reasonably low, and operative mortality ranges from 0.2 percent to 1 percent. Disadvantages of Roux-en-Y gastric bypass include the potential for anastomotic leaks and strictures, severe dumping syndrome symptoms and procedure-specific complications, including distension of the excluded stomach and internal hernias. Roux-en-Y gastric bypass is technically more challenging to perform than the restrictive procedures, particularly when using the laparoscopic approach. In experienced hands, the conversion rate of laparoscopic Roux-en-Y gastric bypass to open is 5 percent.

3 Restrictive Operations Alternatives to gastric bypass procedures are restrictive operations such as vertical-banded gastroplasty (not offered at the Cleveland Clinic) or adjustable gastric banding. Restrictive surgery results in weight loss when the surgeon creates a small pouch at the top of the stomach where the food enters from the esophagus. The pouch's lower outlet usually has a diameter of about 1/4-inch. The small outlet delays the emptying of food from the pouch creating a feeling of fullness. Following surgery, patients can usually eat only one-half to 1 cup of food without discomfort or nausea. Most people who have a restrictive operation lose the ability to eat a large amount of food at one time. Some patients do return to eating modest amounts of food, without feeling overly hungry. Both operations serve only to restrict food intake and do not alter the normal digestive and absorptive process. Vertical Banded Gastroplasty The surgeon uses staples and a plastic band to create a smaller stomach pouch. Patients are unable to eat large quantities of food and do notice a feeling of fullness. Long-term complications such as weight regain and severe acid reflux or difficulty swallowing solids occur in up to one-half of patients who underwent VBG. This procedure is not offered at the Clinic. We do manage patients with complications of VBG and these often require conversion to a gastric bypass. Laparoscopic Adjustable Gastric Banding (LAGB) During the procedure, surgeons typically use laparoscopic techniques and instruments to implant an inflatable silicone band around the upper portion of the stomach. The band creates a new, tiny pouch that limits and controls the amount of food consumed. The band also creates a small outlet that slows the emptying process into the stomach and the intestines allowing the patient to experience an earlier sensation of fullness and increased satisfaction with smaller amounts of food. This ultimately results in weight loss.

4 The LAGB patient can expect a reduced hospital stay of one to two days; in some instances there may be an increased stay if the surgery required an abdominal incision or complications occurred. Patients may resume normal activities in one to two weeks; again, expect a delay if there is an abdominal incision or complications occur. The LAGB procedure requires no cutting or stapling of the stomach and bowel and is considered the least invasive weight loss surgery available. The band is also adjustable and can be modified by inflating or deflating the inner surface with saline solution. The surgeon can control the amount of saline in the band using a fine needle through the skin. The adherence to monthly appointments for band adjustments the first 6-12 months after surgery is very important to achieve optimal results. Once the band is adjusted properly, the duration between visits can be lengthened. The adjustments are made in the surgeon's exam room and patients have minimal discomfort. Finally, should the band need to be removed, the stomach will return to its original form and function. Laparoscopic Sleeve Gastrectomy We perform the Sleeve Gastrectomy as a laparoscopic procedure. This involves making five or six small incisions in the abdomen and performing the procedure using a video camera (laparoscope) and long instruments that are placed through these small incisions. During the Laparoscopic Sleeve Gastrectomy, about 75% of the stomach is removed leaving a narrow gastric tube or sleeve. No intestines are removed or bypassed during the sleeve gastrectomy. The LSG takes one to two hours to complete. Sleeve Gastrectomy is a restrictive procedure. It greatly reduces the size of your stomach and limits the amount of food that can be eaten at one time. It does not cause decreased absorption of nutrients or bypass

5 your intestines. After eating a small amount of food, you will feel full very quickly and continue to feel full for several hours. Sleeve Gastrectomy may also cause a decrease in appetite. In addition to reducing the size of the stomach, Sleeve Gastrectomy may reduce the amount of hunger hormone produced by the stomach which may contribute to weight loss after this procedure. This procedure is primarily used as part of a staged approach to surgical weight loss. Patients who have a very high body mass index (BMI) or who are at risk for undergoing anesthesia or a longer procedure due to heart or lung problems may benefit from this staged approach. Sometimes the decision to proceed with a two-stage approach is made before surgery due to these known risk factors. In other patients, the decision to perform sleeve gastrectomy (instead of gastric bypass) is made during the operation. Reasons for making this decision intraoperatively include an excessively large liver or extensive scar tissue that would make the gastric bypass procedure too long or unsafe. In patients who undergo LSG as a first stage procedure, the second stage (gastric bypass) is performed 12 to 18 months later after significant weight loss has occurred and the risk of anesthesia is much lower (and the liver has decreased in size). Though this approach involves two procedures, we believe it is safe and effective for selected patients. Laparoscopic Sleeve Gastrectomy can also be used as a primary procedure. There is relatively little data regarding the use of LSG as a stand-alone procedure in patients with lower BMI s and it should be considered an investigational procedure in this patient group. We are offering this procedure to diabetic patients with a BMI between 30 and 40 as a part of a clinical trial that will better define the short and longterm benefits of LSG in this group of patients. There are risks that are common to any laparoscopic procedure such as bleeding, infection, injury to other organs, or the need to convert to an open procedure. There is also a small risk of a leak from the staple line used to divide the stomach. These problems are rare and major complications occur less than 1% of the time. Overall, the operative risks associated with LSG are slightly higher than those seen with the laparoscopic adjustable band but lower than the risks associated with gastric bypass. Depending on their pre-operative weight, patients can expect to lose between 40% to 70% of their excess body weight in the first year after surgery. Many obesity-related co morbidities improve or resolve after bariatric surgery. Diabetes, hypertension, obstructive sleep apnea and abnormal cholesterol levels are improved or cured in more than 75% of patients undergoing LSG. Though long-term studies are not yet available, the weight loss that occurs after LSG results in dramatic improvement in these medical conditions in the first year after surgery. Your surgeon may talk to you about LSG as an option if you have a BMI over 60 or significant medical problems that increase your risk for undergoing anesthesia or gastric bypass. Laparoscopic Sleeve Gastrectomy may also be offered as part of a clinical investigation if you have a lower BMI and diabetes. You should discuss all of the available surgical procedures with your surgeon and determine which procedure is best for you.

6 Biliopancreatic Diversion This malabsorptive procedure is less commonly performed and involves a distal gastrectomy, the creation of a long Roux-en-Y limb and an enteroenterostomy 50 to 100 cm from the ileocecal valve to form the common channel. A modification of biliopancreatic diversion (BPD) with a duodenal switch (BPD-DS) consists of a sleeve gastrectomy and duodenoileostomy with a long alimentary limb and a common channel measuring cm. The advantages of BPD include substantial, durable weight loss (> 70 percent beyond 10 years) and resolution of many obesity-related co morbidities. This procedure may be more effective than RYGB or restrictive procedures for super-obese patients and can be used as a secondary procedure in patients who have failed to lose weight with gastric bypass or restrictive procedures. BPD-DS also can be performed laparoscopically. BPD and BPD-DS, particularly if done laparoscopically, are technically challenging operations, and they have higher postoperative complications and operative mortality rates than other bariatric procedures. Metabolic complications occasionally require re-operation to lengthen the common channel.

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